Reflections on travel, philosophy, science, nature, and other musings.

Monday, August 20, 2012

"Joint attention" & child development

I met with a friend and her 14-month-old son today, and a fleeting interaction between the two reminded me again just how fascinated I am by human development.

Basically, the little boy was in the process of doing something he wasn't allowed to do (dump his snack all over his stroller or the floor); he glanced up at his mother with a cheeky look on his face; she made a sort of "playful warning" face in return; he smiled back and didn't continue.

Seemingly everyday interaction, but when I see something like this I am utterly fascinated. So many incredible things happened in those few seconds, and we take them for granted just because of how common they are.

But when you really think about it - how did his mother know that his "cheeky face" meant "I'm thinking about throwing my snack, I want to see what you think about it; I want to see how far I can push it" ? And how did he know "my mommy's expression means I shouldn't continue this; it also means she understands I'm just being "cheeky" and joking with her" ? A myriad of other complex things happened in this few second interaction, but to me just these are enough to write pages about!

As someone who's spent her entire life struggling to understand the complex social information encoded in the "subtext" of language, in facial expression, tone of voice, etc., the ease with which even an infant can do this makes the concept all the more fascinating to me.

(To any MA/PhD clinical psychology programs who might happen to be passing by this blog - yes I really do think about this stuff all the time. I would like to put it to good use! ...please accept me into your program?)

I have actually already written a thorough explanation of the basic phenomenon underlying the interaction between my friend and her son; below is a paper I wrote for a class last year that thoroughly (and in layman's terms!) explains the fascinating phenomenon of "joint attention", as well as how its absence in those with autism may be the root of their language and social difficulties.

____________________________________________

Joint
Attention in Autism

Ana Luisa Santo

Introduction

Deficits in joint attention (JA)
may be one of the earliest indicators of autism (Murray et al., 2008), evident
long before the more salient symptoms (language delay, social difficulties, repetitive
behaviours) become observable.It is
therefore important to understand precisely what is meant by joint attention,
how it affects other aspects of development, how to differentiate it from other
behaviours that appear to be JA but are not, and how to foster joint attention
in those that lack it.

What is
joint attention?

Joint attention refers to a
particular kind of attention that can be referred to as “social attention” –
specifically, attention that is coordinated between two people and an external
object or event.This enables both
parties involved in the social interaction to have a “shared experience”.

Consider
the following scenario: A caregiver is pushing a stroller through the park with
a 1-year-old child.A brightly coloured
bird suddenly lands on the bush beside them.The child is the first to notice, and points at the bird, perhaps
vocalizing “buh” at the same time.The
caregiver turns their head to follow the pointing finger and sees the bird,
then checks back to follow the child’s gaze and confirm that the bird is the
object of interest.The child
simultaneously follows the caregiver’s gaze, and both look back and forth
between each other and the bird, to confirm they are seeing the same
thing.Suddenly the bird flies away, and
the child again exclaims “buh!”, points at the fleeing bird, and checks the
caregivers face to make sure they have also seen this tragic turn of
events.The caregiver might then reply,
“Yes, it was a pretty bird, but it flew away. I’m sad too.”

This
seems like a simple, everyday occurrence – and it is, in typically developing
children.But a number of fascinating
things happen in these everyday moments.When a child points to an object, event, or entity, and then checks to
see if the other person sees the same thing, a powerful thing happens: The
child knows “They see what I am seeing, we are experiencing the same thing.” Not
only this, but the child also knows “They know that I am seeing what they
see.”The other person in the
interaction also knows these two things.This is vital for social interaction.Without this shared knowledge and awareness
that the knowledge is shared, conversation would be quite difficult.

In
the above example, the caregiver shared multiple things with the child: The
creature in question was called “bird”, the bird had the quality of “pretty”,
the bird’s movement was referred to as “flew away”, the caregiver experienced
sadness about this, and, the caregiver recognized the child’s sadness
also.These, again, may seem self-evident
points, barely worthy of mention.But
consider the following similar scenario:

A
caregiver is walking through the park with their 10-year-old child, who has
autism.A brightly coloured bird
suddenly lands on the bush beside them.The child is the first to notice and stops walking to watch the
bird.The caregiver follows the child’s
gaze and points at the bird, saying “That’s a pretty bird”.The child is briefly distracted by the
outstretched arm, then looks back at the bird.Suddenly the bird flies away, and the child jumps up and down and
vocalizes loudly.The caregiver,
recognizing their child’s frustration, says “The bird flew away; I’m sad too.”

In
this very similar scenario, there is one key difference: The child has no way
of knowing if the caregiver is seeing what they see.Even if the child had no problems with
language comprehension, the bird referred to by the caregiver could have been
some other bird; the caregiver could have been on the telephone; or they could
have been sharing that particular bird experience with a passerby.The child neither pointed out the bird
themselves, nor checked the caregivers gaze to see if they were looking at the
same thing.

Because
of this, the experience was not a shared one.When the caregiver says “That’s a pretty bird” or “The bird flew away;
I’m sad too”, the child has no basis for connecting the words “bird” or “flew
away” to any aspect of the event.The
child also had no basis for perceiving that their frustration or sadness was
seen and understood by the caregiver.Since a shared experience did not happen, not only is social conversation
not possible, but neither is any aspect of typical language learning.Suddenly, the difference between a typical
infant and an older autistic child becomes almost painfully clear.

Development
of Joint Attention

As outlined above, joint
attention is often initiated by visual cues (eye gazes; pointing).Before language and the ability to move
about, these are the main behaviours that infants have at their disposal for
initiating a bid for joint attention.Infants are very sensitive to social stimuli as early as birth (Rochat
& Striano, 1999); i.e., they are predisposed to orient towards faces
(Frank, Vul & Johnson, 2009).By
around 5 months of age, they begin to demonstrate sensitivity to very small
shifts in the eye gazes of adults (by smiling and attending less if they
perceive the adult is no longer looking at them) (Symons, Hains & Muir,
1998).It is thought that joint attention
emerges at no later than 8-9 months of age (Mundy et al., 2007) and it may in
fact emerge as early as 5 months (Legerstee, Markova, & Fisher, 2007).Joint attention skills then continue to
develop in predictable patterns (Bruinsma, Koegle, & Koegel, 2004), and
increase significantly between 6 and 18 months of age (Bakeman & Adamson,
1984).

In
comparison, children with autism appear to have severe delays in, or complete
absence of many aspects of joint attention, with the difficulties continuing
into late childhood (Loveland & Landry, 1986).

The
deficit in joint attention seen in children with autism is not necessarily a
deficit of ability, but rather one of desire – those with autism do not appear
to find it rewarding to attend socially or initiate social interactions;
therefore they do no feel the need to respond to or initiate JA bids.

Responding
to Joint Attention & Initiating Joint Attention

Joint attention can be further
broken down into two separate skills: responding to joint attention (RJA) and
initiating joint attention (IJA).Responding to a bid for joint attention refers to an infant’s ability to
recognize when another is drawing their attention to something, typically by
pointing or looking at it.This ability
can be assessed around 3-6 months by seeing whether infants correctly follow
others’ gazes by turning their heads and/or eyes (Mundy, in press).Initiating a bid for joint attention is
thought to be a more complex skill and to develop a little later.It involves initiating a shared experience (i.e. by pointing).

It
is important to understand and be able to differentiate between instances of
true RJA/IJA from merely responding to behaviour requests (RBR), or initiating
behaviour requests (IBR).An example of
RBR would be an adult pointing to the last piece of broccoli because they want
the child to finish their dinner, and the child complying by eating it. (Toppling
the offending vegetable to the ground would also be an equally valid “response”
to the behaviour request, yet still not necessarily RJA).An example of IBR would be a child pointing
at a cookie, not to have the shared experience of admiring the baked good, but
to simply request it for consumption.

On
the surface, RJA/RBR and IJA/IBR may look the same (they both involve either
responding to points/gazes or initiating an interaction via points/gazes).The vital difference between the two pairs is
the intent behind the
initiation.If the intent is simply to
gain access to a desired object (IBR), this is not true joint attention.The difficulty lies, of course, in assessing
an individual’s intent, especially in populations that cannot necessarily be
questioned verbally (i.e. those with autism).

Joint
attention and language development

Joint attention has been shown to
be important in the development of language (Bruinsma, Koegle, & Koegle,
2004; Kuhl, 2007).Kuhl (2007) has
hypothesized that a “social brain” is necessary for language development.In an experiment that exposed 9 month-old
infants to a foreign language, the results showed that those children who were
exposed to it via television or audio did not show any evidence of learning,
while those exposed to the language by a human being who interacted socially
with them were later able to distinguish between the phonemes of the foreign language,
something the other groups were unable to do (Kuhl et al., 2003, as cited in
Kuhl, 2007).

Since
joint attention is a precursor to more complex social behaviours, it makes
sense to hypothesize that it is necessary for language development – indeed, a
longitudinal study which looked at 9-month olds’ understanding of referential
pointing showed that this aspect of joint attention was related to later
vocabulary gains at 24 and 36 months (Kristen, Sodian, Thoermer, & Perst,
2011).

The
theory is that if a child does not orient to adults’ gaze/pointing (RJA), they
are deprived of situations to learn language.Similarly, if a child does not IJA, even situations of intrinsic
interest to the child cannot provide opportunities for language learning
(Mundy, in press).Therefore, a child
with autism may experience deficits in language that are caused (at least in
part) due to lack of joint attention.

The lack
of joint attention as the core deficit in autism

Mundy describes the far-reaching
effects of JA deficits well:

“Without the capacity for joint
attention, success in many pedagogical contexts would be difficult.Imagine the school readiness problems of a five-year-old who enters kindergarten but is not facile
with coordinating attention with the teacher.Similarly, children,
adolescents and adults who cannot follow, initiate or join withthe rapid-fire exchanges of shared social
interactions may be impaired in any social-learning
context, as well as in their very capacity for relatedness and relationships.” (in press).

Mundy
highlights the idea that considering those with autism as having a complete
lack of responsiveness to other people is inaccurate.Many children with autism display levels of
attachment that are on par with their mental development (Shapiro, Sherman,
Calamari, & Koch, 1987, as cited in Mundy, in press).They are also able to learn form social
modeling, respond when they are imitated, and make some use of eye contact and
gestures to communicate (e.g. Mundy & Sigman, 1989, as cited in Mundy, in
press).

Mundy
writes that, instead, the “lack of spontaneous seeking to share enjoyment,
interests, or achievements with other people” (American Psychiatric
Association, 2000) (in other words, initiating joint attention) is central to
the understanding of autism.Children
with autism are specifically lacking the desire
to initiate or respond to social attention (not the ability), most likely
because they do not find it inherently rewarding.Since joint attention behaviours can be seen
in very young infants, while other measures of social skills must wait until
the child is older, they are potentially a very useful diagnostic tool.

Teaching
joint attention

Many have deigned methods to
teach joint attention, with varying results.White and colleagues have done a systematic review of 27 studies that
attempted to teach joint attention (2011). Success has been found with shaping
RJA attention behaviours (i.e., teaching a child to respond to the tapping of
an object, and gradually shaping to be able to respond to pointing).Most of the interventions for teaching joint
attention were in the context of play.Teaching this skill during play is important, because it allows children
to generalize the skill to other contexts.When desired behaviours related to joint attention were produced, some
type of reinforcement was always used.

While
many of the studies seemed to show positive outcomes in teaching joint
attention, one has to step back and examine the results critically.Meindl & Canella-Malone have also done a
literature review specifically to examine what was truly being taught in
studies that claimed to have successfully taught joint attention (2011).For example, out of 11 studies that focused
on teaching IJA, 9 provided access to the object as a reward.Therefore it is unknown whether they were
teaching true IJA, or simply IBR.The
use of rewards other than social rewards is “particularly troublesome”, according
to the authors.In natural instances of
IJA, the “reward” by the initiator is never the object of interest – it is the
social interaction itself.

This
raises the question of whether joint attention can be taught at all – for how
does one “teach” another to become intrinsically rewarded by social attention?
There are no easy answers to this question; however, it is something to keep at
the front of one’s mind when developing or reading about methods for teaching
joint attention.

Joint
attention in children with congenital blindness

Because congenitally blind
infants cannot initiate or respond to joint attention via conventional methods
(points/gazes), do they have deficits in developing RJA and IJA? There are anecdotal clinical reports on the
similarities between blind and autistic children (e.g. Brown, Hobson, &
Lee, 1997; Hobson, Lee, & Brown, 1999).

A
case study of two congenitally blind infants was done by Bigelow (2003).She showed that these infants were indeed
delayed in their development of JA.Because blindness makes it difficult to detect what others are attending
to, infants must depend on others to initiate social interaction, and only
after they develop language do they have a means of initiating joint attention
themselves.

Because
most blind children eventually acquire JA, normal language, and social abilities,
visual joint attention does not seem to be necessary for language
acquisition.It may be possible that
whatever methods are used to develop JA in congenitally blind children (i.e.
tactile/auditory methods) may be useful for teaching JA to children with autism
(Santo, 2011).

Conclusion

It is clear that joint attention
deficits play a great role in autism, and may in fact underlie most of the main
symptoms, such as language delay and deficits in social ability.It is important to keep in mind the distinctions
between RJA/RBR and IJA/IBR, especially when considering the literature on
methods for teaching JA.Considering
joint attention as the core deficit in autism is potentially a valid diagnostic
tool for recognizing autism in very young children, and future research should
focus on examining how best to do this.